Insert and insert system for a laparoscopic instrument

ABSTRACT

An insert  30  comprises a rod  32  having a proximal end  34  and a distal end  36.  The insert  30  also comprises a tool  38  which is demountably coupled to the distal end  36.  Proximal end  34  is formed with a ball  40  which is configured to seat and engage in a socket of a handle  12  of a laparoscopic instrument  10.  The rod  32  fits within a sheath  14  of the laparoscopic instrument  10.  The distal end  36  of the rod  32  is provided with an attachment head  42  to facilitate the attachment of the tool  38.  A linkage mechanism  44  in the attachment head  42  converts the linear motion of the insert  30  (and in particular rod  32 ) relative to the outer sheath  14  to a pivotal motion.

CROSS-REFERENCE TO RELATED APPLICATION

This application claims the benefit of U.S. Provisional Application Ser.No. 61/583,755 filed on Jan. 6, 2012 and U.S. Provisional ApplicationSer. No. 61/701,883 filed on Sep. 17, 2012, the contents of whichapplications are herein incorporated by reference in their entirety.

FIELD OF THE INVENTION

The present invention relates to an insert and an insert system for alaparoscopic instrument.

BACKGROUND OF THE INVENTION

A laparoscopic instrument comprises a handle, an outer sheath, and aninsert. The outer sheath may be fixed to or alternately detachable fromthe handle. The insert extends through the sheath and is operativelycoupled to the handle. The handle has two finger rings similar to aregular pair of scissors. When the handle is manipulated by squeezingtogether the finger rings or pushing them apart the insert is movedlinearly relative to the outer sheath. The insert is provided at itsdistal end with an integrated tool. Linear motion of the insert relativeto the sheath operates the tool. This may be manifested for example bythe opening and closing of jaws or blades of the tool. The function andnature of this tool determines the type of insert. Types of insertsinclude scissors, dissectors, forceps and needle holders. Moreover,there are many variations within each type of insert. For example,scissor inserts are available as straight, curved, fine, parrot beak,serrated, single or double action scissor inserts. Dissector inserts areavailable as duck bill, Maryland, round nose, bottle nose, and mixter.

Depending on the type of laparoscopic surgery at hand, a surgeon willrequire a large range of laparoscopic instruments with specific inserts.

Also, while there are currently many different types of insertsavailable, some of these inserts require very high levels of surgicalexpertise and competence in order to avoid accidental injury topatients. Indeed the level of expertise required while maintainingpatient safety may at times be beyond many surgeons.

SUMMARY OF THE INVENTION

In one aspect the invention provides an insert for a laparoscopicinstrument having a handle and an outer sheath coupled to the handle,the insert comprising:

a rod configured to fit within the outer sheath and engage at itsproximal end the handle; and

a tool demountably coupled to a distal end of the rod.

In one embodiment the insert comprises a linkage mechanism whichconverts linear motion of the rod relative to the outer sheath to apivotal motion of, or a component of, the tool of up to at least 150°.

In one embodiment the tool is provided with a suture aperture openingfor receiving a suture.

In one embodiment the suture opening is either a suture hole or a sutureslot wherein the suture slot extends along a length of the tool and isprovided with an opening enabling a suture material to enter the sutureslot.

In one embodiment the tool comprises a suture needle.

In one embodiment the needle comprises a straight shaft.

In one embodiment the needle comprises a curved shaft.

In one embodiment a distal end of the needle: (a) tapers conically to apoint; (b) tapers linearly to a point to produce a cutting edge; or (c)is provided with a rounded end.

In one embodiment the tool comprises a ureteric tunneller having eithera straight shaft provided with one of a spherical tip or an ellipsoidtip; or curved shaft provided with one of a spherical tip or anellipsoid tip.

In one embodiment the tool comprises a dissector.

In one embodiment the dissector comprises a shaft, a reduced thicknesstip at a distal end of the shaft and a straight edge at a distal end ofthe tip lying perpendicular to a length of the shaft.

In one embodiment the reduced thickness tip has at least one planarsurface.

In one embodiment the reduced thickness tip is curved in configuration.

In one embodiment insert comprises a longitudinal slot formed in thereduced thickness tip and opening onto the straight edge.

In one embodiment the shaft is provided with a dovetail shaped slotextending along a longitudinal axis of the shaft and inboard of the tip.

In one embodiment the tool comprises a myoretractor having either astraight shaft or a corkscrew shaped shaft.

In one embodiment the tool comprises a myoretractor having a straightshaft and a hook at a distal end of the shaft.

In one embodiment the tool comprises a scalpel.

In one embodiment the tool comprises a peeling blade provided with alongitudinal slot the slot having mutually facing longitudinal cuttingedges.

In a second aspect the invention provides an insert system for alaparoscopic instrument having a handle and an outer sheath coupled tothe handle, the insert system comprising;

a rod configured to fit within the outer sheath and engage at itsproximal end the handle; and

a plurality of tools each being demountably attachable to a distal endof the rod.

In one embodiment the plurality of tools comprises at least two tools ofdifferent configuration.

In one embodiment the plurality of tools comprise one or more of thetools as described hereinabove in relation to the first aspect.

In a third aspect there is provided a laparoscopic instrumentcomprising:

a handle;

an outer sheath coupled to the handle; and,

an insert in accordance with the first aspect, the insert being disposedwithin the outer sheath and operatively coupled at a proximal end withthe handle.

In a fourth aspect there is provided a laparoscopic instrument systemcomprising:

a handle;

an outer sheath coupled to the handle; and,

an insert system according to the second aspect.

In a fifth aspect there is provided a laparoscopic suture system forfacilitating laparoscopic surgery, the laparoscopic suture systemcomprising:

an elongated rod provided at one end with a tool having with a holethrough which a suture can pass; and,

a handle coupled to an opposite end of the elongated rod, the roddimensioned to enable the tool to be located internal of a bodyundergoing laparoscopic surgery while the handle is located externallyof the body.

In one embodiment the tool is movably coupled to the elongated rod andthe handle is coupled to the tool to selectively move the tool relativeto the rod upon manipulation of the handle.

In one embodiment the tool is pivotally coupled to the rod whereinmanipulation of the handle affects a pivotal motion of the tool or aportion thereof relative to the rod.

In one embodiment the laparoscopic suture system comprises a releasablelocking mechanism arranged to enable the position of the tool relativeto the rod to be releasably locked.

In one embodiment the tool is demountably coupled to the elongated rodwherein rod can be decoupled from the elongated rod when in vivo toenable withdrawal of the elongated shaft from the body while the tipportion remains in vivo and subsequently enabling re-coupling of the tipportion to the elongated shaft upon re-entry into the body.

A sixth aspect provides a tool for a laparoscopic instrument.

BRIEF DESCRIPTION OF THE DRAWINGS

Embodiments of the present invention will now be described by way ofexample only with reference the accompanying drawings in which:

FIG. 1 is a representation of a prior art laparoscopic instrument in adisassembled state;

FIG. 2 is a representation of an embodiment of an insert in adisassembled state for a laparoscopic instrument;

FIG. 3a is a representation of a linkage mechanism incorporated in theinsert shown in FIG. 2 when in a first state;

FIG. 3b is a representation of the linkage mechanism incorporated in theinsert shown in FIG. 2 when in a second state;

FIG. 4a is an isometric view of an insert with an alternative linkagemechanism;

FIG. 4b is a view of detail O in FIG. 4 a;

FIG. 4c is an end view of the insert shown in FIG. 4 a;

FIG. 4d is a view of section R-R of shown in FIG. 4 c;

FIG. 5a is a representation of an embodiment of a tool in the form of aneedle that can be used with or incorporated in the insert shown in FIG.2;

FIG. 5b illustrates an embodiment of a tool in the form of a needlewhich differs from that shown in FIG. 5a by way of its coupling portion;

FIG. 6a depicts an embodiment of a tool in the form of a ski needle thatcan be used with or incorporated in an insert shown in FIG. 2;

FIG. 6b depicts an insert incorporating the ski needle shown in FIG. 6a;

FIG. 6c depicts an end portion of the insert shown in FIG. 6b but withthe ski needle pivoted with respect to a shaft of the insert;

FIG. 7a is a representation of the tool in the form of a ski needlewhich is of greater length than that shown in FIG. 6 a;

FIG. 7b depicts an insert incorporating the ski needle shown in FIG. 7a;

FIG. 7c depicts an end portion of the insert shown in FIG. 7b but withthe ski needle pivoted with respect to a shaft of the insert;

FIG. 8a is a representation of a tool in the form of a ureterictunneller that may be used with or incorporated in the insert;

FIG. 8b is a representation of a tool in the form of a ureterictunneller but of a different configuration to that shown in FIG. 8 a;

FIG. 8c is a representation of a tool in the form of a ureterictunneller having a head of different configuration to that shown inFIGS. 8a and 8 b;

FIG. 9 is a representation of a tool in the form of a dissector that maybe used with or incorporated in the insert;

FIG. 10a is a side view of a tool in the form of a dissector ofdifferent configuration to that shown in FIG. 9;

FIG. 10b is an isometric view of the dissector shown in FIG. 10 a;

FIG. 10c is an enlarged plan view of a distal end of the dissector shownin FIG. 10 a;

FIG. 11a is a side view of a tool in the form of a dissector ofdifferent configuration to that shown in FIGS. 9 and 10 a;

FIG. 11b is an isometric view of the dissector shown in FIG. 11 a;

FIG. 11c is a plan view of a distal end of the dissector shown in FIG.11 a;

FIG. 12 is a representation of a tool in the form of a myoretractor thatcan be used with or incorporated in an insert;

FIG. 13a is a side view of a tool in the form of a myoretractor ofdifferent configuration to that shown in FIG. 12;

FIG. 13b is an isometric view of the myoretractor shown in FIG. 13 a;

FIG. 13c is a side view of a tool in the form of a cork screwmyoretractor that can be used with or incorporated in an insert in analigned configuration with a shaft of the insert;

FIG. 13d is an isometric view of the cork screw myoretractor shown inFIG. 13c but with the tool pivoted with respect to the shaft of theinsert;

FIG. 14 is a representation of a tool in the form of a cutting edgeneedle that may be used with or incorporated in the insert;

FIG. 15 is a representation of a tool in the form of a GI retractor thatcan be used with or incorporated in the insert;

FIG. 16a is a side view of a tool in the form of a ski needle providedwith a suture slot that may be used with or incorporated in an insert;

FIG. 16b is a side view of an insert incorporating the ski needledepicted in FIG. 16 a;

FIG. 16c is a view of an end portion of the insert shown in FIG. 16b butwith the ski needle in a pivoted position with respect to a shaft of theinsert;

FIG. 17 is a representation of a tool in the form of a scalpel that maybe used with or incorporated in the insert;

FIG. 18 is a representation of a tool in the form of a peeling bladethat may be used with or incorporated in the insert;

FIG. 19 is a representation of a tool in the form of a telescope anddilator that may be used or incorporated in the insert;

FIG. 20 is a representation of a coupling portion for a scalpel bladeenabling a scalpel blade to be presented at two mutually perpendicularangles;

FIG. 21a is a representation of an insert provided with a tool in theform of a myoma drill and incorporating a further form of linkagemechanism;

FIG. 21b is a view of a portion of the insert shown in FIG. 21a but withthe tool pivoted relative to a rod of the insert; and,

FIG. 21c is an enlarged plan view of a portion of the linkage mechanismshown in FIG. 21 a.

DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS

To provide context to embodiments of the present invention reference ismade to FIG. 1 which depicts a conventional manual laparoscopicinstrument 10. The instrument 10 comprises three primary componentsnamely a handle 12, an outer sheath 14, and an insert 16. The insert 16comprises a rod 18 which is provided with a ball 20 at a proximal endand a tool 22 at an opposite distal end. The ball 20 is seated in asocket (not shown) in the handle 12 to provide mechanical couplingbetween the handle 12 and the insert 16. The handle 12 is formed withtwo arms or levers 15 that are pivotally coupled together. A finger ring17 is provided at an end of each arm 15 to enable gripping of the handle12. A releasable lock mechanism 19 is attached between the arms 15 andis operable to hold the arms 15 at fixed angle relative to each other.

Prior to the insert 16 being coupled to the handle 12, it is insertedinto the outer sheath 14 so that the tool 22 is adjacent a distal end 24of the sheath 14. When in this configuration, the ball 20 of insert 16extends beyond proximal end 26 of the sheath 14. A screw coupling 28 isprovided at the proximal end 26 to enable attachment of the sheath 14 tothe handle 12. The insert 16 includes a mechanical linkage system whichoperates to convert linear motion of the rod 18 within sheath 14 into apivotal motion of one or more elements of the tool 22.

Thus when the instrument 10 is in an assembled state the insert 16 isdisposed within the outer sheath 14 with the tool 22 extending from adistal end 24 and; the ball 20 of insert 16 and coupling 28 of sheath 14are both coupled to different sections of the handle 12. The handle ismanipulated by inserting the thumb and forefinger in respective fingerrings 17 and squeezing the rings 17 together or pushing them apart topivot the arms 15 toward or away from each other. This causes the rod 18to move linearly within and with respect to the outer sheath 14. Thislinear motion is translated into a pivoting motion by virtue of thelinkage system and activates or otherwise manipulates the tool 22 toperform its intended function. Thus for example in the event that theinsert 16 is a forceps, this action will result in jaws of the forcepsopening or closing depending on whether the motion of the relativeposition of the finger rings 17.

The function of the laparoscopic tool 10 is determined by the nature ofthe insert 16. For any particular surgical procedure a surgeon may havea large range of instruments 10 which differ only in relation to theinsert 16 in order to complete the surgical procedure at hand.

FIG. 2 depicts an embodiment of an insert 30 in accordance with thepresent invention when in a disassembled state. The insert 30 comprisesa rod 32 having a proximal end 34 and a distal end 36. The insert 30also comprises a tool 38 which is demountably coupled to the distal end36. Proximal end 34 is formed with a ball 40 which is configured to seatand engage in a socket of the handle 12 of a laparoscopic instrument 10.The distal end 36 of the rod 32 is provided with an attachment head 42to facilitate the attachment of the tool 38.

FIGS. 3a and 3b illustrate one form of linkage mechanism 44 for theattachment head 42 that converts the linear motion of the insert 30 (andin particular rod 32) relative to the outer sheath 14 to a pivotalmotion. The linkage mechanism 44 comprises four arms 46 a-46 d that arepivotally coupled together. Specifically arms 46 b and 46 c are bothpivotally coupled to one end of the rod 32 about a pivot point 48. Anopposite end of arm 46 c is pivotally connected to one end of arm 46 dabout pivot point 50. Arm 46 a is pivotally coupled at one end to thearm 46 b via a pivot point 52. An opposite end of the arm 46 a and oneend of the arm 46 d are pivotally coupled to one end of a common pivotpin 54. An opposite end of the pivot pin 54 is held in one arm of abifurcation of the attachment head 42. The coupling piece 58 a isattached to pivot point 50 and extend from a slot created by thebifurcated arm 56. The coupling piece 58 a couples with a complimentarycoupling piece 58 b on the tool 38. A reduced diameter boss 60 extendsfrom an end of the bifurcated arm 56 distant the fixed pivot point 54.

When the insert 30 is attached to the handle 12 and located within theouter sheath 14, the boss 60 fits inside the end of the outer tube 14while the bifurcated arm 56 extends from the end of the sheath 14. Whenthe handle 12 is manipulated, causing the insert and in particular therod 32 to move linearly, the linkage mechanism 44 operates to effect apivotal motion of the coupling piece 58 a.

Reverting back to FIG. 2, the tool 38 in this instance comprises acurved suture needle having a curved shaft 62 which extends from thecoupling portion 58 b. A suture hole 64 is formed near a distal end 66of the needle. In this instance, the distal end 66 is terminated in arounded tip 68.

The coupling parts 58 a and 58 b may be in the form of complimentaryscrew threads. Alternately the coupling portions 58 a and 58 b may takemany other forms including but not limited to luer lock couplers.Irrespective of the specific nature of the coupling portions 58 a and 58b the provision of the coupling portions enables the tool 38 to beinterchanged at will.

FIGS. 4a-4d show an insert 30 a provided with an alternate linkagemechanism 44 a. The insert 30 a comprises a tube 33 having a slot 35 atone end creating spaced arms 37 a and 37 b and an increased outerdiameter seat 39. An internal rod 32 a extends through a central bore inthe tube 33. One end of the tube 33 is provided with a ball 40 that liesin the seat 39. An opposite end of the rod 32 a that extends into theslot 35 is bent and pivotally connected to a coupling part 58 a by apivot pin 57. The coupling part 58′ is itself connected by a pivot pin48 a to the arms 37 a and 37 b. The pivot pins 48 a and 57 are offsetform each other to create a lever mechanism. Thus when the rod 32 a ismoved linearly relative to the tube 33 the coupling part 58 a will pivotabout the pivot pin 48 a. The rod 32 a can be moved linearly relative tothe tube 33 by fitting the tube 33 into the sheath 14 and engaging theball 40 in a socket of the handle 12 of a laparoscopic instrument 10,and subsequently manipulating the handle 12.

FIGS. 5a-5h depict embodiments of other tools that may be demountablycoupled to the rod 32 to form different types of inserts 30. FIGS. 5aand 5b depict tools 38 a and 38 b in the form of suture needles. Bothneedles 38 a and 38 b differ from the needle 38 shown in FIG. 2 by theprovision of a straight needle shaft 62 a and 62 b respectively.Otherwise the tool 38 a is the same as tool 38. However with the tool 38b, the coupling portion is in the form of a luer lock coupling portion58′b.

The provision of tools 38 in the form of suture needles is particularlyuseful for laparoscopic suturing and as explained below has manybenefits over prior art laparoscopic suturing.

Prior art laparoscopic suturing requires a laparoscopic needle holder, alaparoscopic grasping forceps, and a suture needle held by thelaparoscopic needle holder. A distal end of the laparoscopic needleholders and the suture needle are passed into the body through a trocar.In order to introduce a trocar into the body an incision is first madein the body. The length of the incision is dependent upon the diameterof the trocar. Most trocars used in laparoscopic surgery have an innerdiameter of 5 mm or 10 mm. This limits the degree of curvature of asuture needle that can be passed into the body through such trocars.Indeed often the best suture needle for a particular procedure will havea curvature that prevents it from being passed through such trocars.

On possible solution to this problem is to use straight or ski shapedneedles. However such needles may not suitable for many suturingsituations. A further option to enable the use of a curved needle is touse a larger diameter trocar. But this has the disadvantage of requiringa larger incision. Another solution is to push the needle directlythrough tissue into the body cavity in which the surgery is beingconducted. This runs the risk of the needle breaking and/or becomeembedded in muscle.

Once the suture needle is located in the body cavity, it is grasped by alaparoscopic needle holder which itself enters the body through atrocar. An intracorporeal laparoscopic needle holder is provided withtwo jaws to enable the gripping of a suture needle at right angles tothe axis of the jaws so that a point of the needle can be driven intotissue or pedicle being sutured. Laparoscopic suturing requires aspecial skill when performed in this manner. Manipulating the needleinto a suturing position when at right angles to the jaws requiresprecise and steady hand-eye coordination. Any deficiencies incoordination and dexterity may lead to unintentional puncturing orinjury of organs or vessels. A straight or a ski needle requires evengreater dexterity. The suturing procedure is performed by viewing a TVmonitor. After passage through the tissue or pedicle, opposite ends ofthe suture are put together and a knot is made, either by intracorporealtying where the knot is made internally by using two graspers; or byextracorporeal tying, where two ends of the suture are taken out througha trocar and a knot is made externally and then passed back through thetrocar into the body. By repeating this process a line or bundle oftissue can be sutured and secured.

Inserts in accordance with embodiments of the present invention whichincorporate the suture needles 38, 38 a and 38 b may greatly assist inovercoming the difficulties associated with conventional laparoscopicsuturing. This is because the laparoscopic instrument 10 with an insert30 in accordance with embodiments of the present invention, for exampleinserts 30 with one of the tools 38, 38 a, 38 b can be introducedthrough a standard trocar into the body cavity. The curvature of astandard needle used in prior art laparoscopic suturing can bereplicated by inserts 30 by manipulation of the handle 10 which willresult in a pivoting of the needle about pivot pin 54. The insert 30 canbe arranged so that the suture needle pivots to an angle of 130° toencircle pedicle. Indeed, complete angulation to 180° can be provided byappropriate configuration of the linkage mechanism 44. The overalleffect is the same as having a needle of a curve between 130° and 180°but with ability to introduce the needle through a 5 mm or 10 mm trocar.Further, as the suture needle is detachably coupled to the shaft 32 ofthe insert 30, it is possible to detach and reconnect the needle in vivoto the same or different laparoscopic tools.

Further embodiments of the tools 38 will be described with reference toFIG. 6a -18. In these descriptions the same reference numbers will beused to denote the features that are identical. However where featuresare generally analogous though not identical the same reference numberis used but with the addition of an alphabetic letter suffix and/or aprime (′) symbol.

FIG. 6a illustrates a further tool in the form of a ski needle 38 c,while FIGS. 6a and 6c depict an insert 30 c which comprises the skineedle 38 c. The ski needle 38 c has a curved shaft 62 that extends froma coupling portion 58 b and is curved at its distal end 66 terminatingin a point 68 c. A suture hole 64 is formed just over half way betweenthe coupling part 58 b and the point 68 c. In this particular embodimentthe shaft 62 c extends for a distance x=20 mm from the coupling 58 b andthe suture hole 64 is a linear distance of y=9 mm form the point 68 c.FIGS. 6b and 6c show the insert 32 c with ski needle 38 c attached tothe shaft 32. In FIG. 6b the insert 30 c is in an insertion state wherethe insert 30 c coupled to an instrument 10 can be inserted through atrocar into a body cavity. In this state the straight portion of theshaft 62 c of the ski needle 38 c is parallel and substantiallyco-linear with shaft 32. FIG. 6c shows a distal end of insert 30 c in anactive state where the needle 32 c has been pivoted by about 120° andbeing used to suture tissue.

FIGS. 7a-7c illustrates a ski needle 38 c′ and associated insert 30 c′that differs from the ski needle 38 c and insert 32 c of FIGS. 6a-6conly in its increased overall length. In the ski needle 38 c′ thedistance x=35 mm.

FIGS. 8a-8c illustrate further tools in the form of ureteric tunnellers38 d, 38 d′ and 38 d″ (hereinafter referred to in general as“tunnellers”). Each of the tunnellers 38 d and 38 d′ comprises acoupling portion 58 b at one end, an intermediate shaft 62 d/62 d′provided with a suture hole 64, and a spherical end or tip 68 d. Thespherical end or tip 68 d has a diameter several times larger than thatof the corresponding shaft 62 d or 62 d′. The tunnellers 38 d and 38 d′differ only in the configuration of their respective shafts. In thetunneller 38 d, a straight shaft 62 d extends between the couplingportion 58 b and the tip 68′. However in the tunneller 38 d′, a curvedshaft 62 d′ extends between coupling portion 58 b and tip 68′.

The tunneller 38 d″ differs from tunneller 38 d by way of the shape ofits tip 68 d″. In the tunneller 38 d″ the tip 68 d″ is of an ellipsoidshape rather than being spherical. The shaft 62 d″ of the tunneller 68d″ can be made to various different lengths, such as for example about30 mm or 50 mm. In one embodiment of the tunnellers the suture hole 64may be about 17 mm form a distal end of the tip 68. In one variation theshaft of the tunneller 68 d″ can be curved rather than straight.

Ureteric injuries can occur during laparoscopic hysterectomy and insurgery involving pelvic side walls. One precaution taken to preventureteric injuries involves dissecting out and displaying the uterus, aprocedure that in itself may cause ureteric damage. Another is to insertureteric cannulas to provide a tactile indicator of the position of theureter. Yet another method is to insert an illuminated ureteric cannulainto the ureter.

The tunnellers described may be used to reduce the risk of uretericinjuries. One use of the tunnellers is as follows. Firstly, thetunneller is connected to the rod 32 to form an insert 30. The insert 30is then coupled to a standard laparoscopic instrument 10. The lateralpelvic wall peritoneum is pulled up and a small incision is made in itover the underlying ureter. The tunneller is angled to run parallel tothe ureter and the spherical/ellipsoid tip 68 is inserted into theincision and pushed forward and moved in a semi-circular motion to freethe peritoneum over the underlying ureter. When a predetermined lengthof ureter is freed under the peritoneum, the peritoneum underlying thespherical/ellipsoid tip 68 is incised and suture material previouslythreaded through suture hole 64 is pulled out. The tunneller is thenwithdrawn leaving the suture material to act as a visual marker to theposition of the ureter. A colored and dissolvable suture material suchas 10 vicryl may be used.

The tunnellers can be made of a non-conducting plastic material to allowelectrosurgical energy to be used to incise the peritoneum over thetunneller.

The ureteric tunneller can be used to free deeper structures in thelateral pelvic side walls such as the internal iliac arteries and veins,to obtain lymph nodes from the pelvic side walls for biopsy. A suturecan be placed around an organ or vessel in this position.

The ureteric tunneller can also be used in a similar manner to freetissue around other organs in the abdominal and pelvic cavities. Thesuture hole provides the placement of a suture around a tissue orvascular pedicle and acts as a marker for the surgeon.

FIGS. 9-11 c illustrate various embodiments of tools in the form ofdissectors. FIG. 9 shows a basic form of the dissector 38 e. Thedissector 38 e comprises a coupling portion 58 d at one end to enablecoupling to the coupling portion 58 a of a rod 32. A shaft 62 e extendsfrom the coupling portion 58 b and terminates in a reduced thickness tip68 e which provides a planar dissecting surface 67. The shaft 62 e iswider than corresponding shafts of the previously described tools toprovide a broader base for the dissecting surface 67. In this regard,the dissecting surface 67 may be made for example of a width of between5 mm to 10 mm. The dissecting surface is a planar surface which issloped relative to a longitudinal axis of the tool 38 e. The reducedthickness tip 68 e and the surface 67 terminate is a straight edge 69that lies perpendicular to the longitudinal axis of tool 38 e. A suturehole 64 is provided behind the tip 68 e to receive a suture or tape. Itis envisaged however in an alternate embodiment that the dissector 38 ecan be provided without a suture hole 64.

Laparoscopic surgery involves the displaying and identification oftissue. Trauma and injuries to various tissue and organs result frominadequate dissection. In conventional laparoscopic surgery, thedissection is performed by scissors and forceps. These provide narrowand sharp presenting points which can result in accidental injury totissue and blood vessels notwithstanding expertise of the surgeon.Embodiments of the inserts 30 that comprise the dissector 38 e canassist in reducing injury due to the substantial (i.e. broad) dissectingtip 68 e. This provides a large presenting part to reduce the risk ofpenetration of tissue or blood vessel. The provision of the suture hole64 behind the dissecting tip 68 e enables a suture or tape to be placedaround or behind the tissue or organ being dissected.

FIGS. 10a-10c show a modified form of dissector 38 e. The dissector 38e′ differs from the dissector 38 e by the: omission of the suture hole64; curvature of the reduced thickness tip 68 e; and, shape of the shaft62 e. The tip 68 e is tapered in thickness in a direction away from thecoupling 58 b and formed with a plurality of contiguous planar surfaces67 on a concave side of the tip 68 e. The shaft 62 e′ is also formedwith a dovetail shaped cut out 71. The dissector is used with the curvedtip 68 e′ facing down so that tissue can be pushed away with the tip 68e′. The slot 71 can be placed on a corner of a uterus and used as atraction hook.

FIGS. 11a-11c show a dissector 38 e″ that differs from dissector 38 e′only by the provision of a linear slot 73 in the tip 68 e″. The slot isopen at one end and terminates in a region near the inner most of planarsurfaces 67. In one embodiment the slot 73 may have a length in theorder of 10 mm and a width of about 0.6 mm. The slot 73 is used to allowplacement of a piece of mesh which can be pulled out and placed overtissue or organs.

FIG. 12 depicts a tool 38 f in the form of a myoretractor. Themyoretractor 38 f comprises a coupling portion 58 b at one end, atapered shaft 62 f extending from the coupling portion 58 b, andterminating in a conically tapered point 68 f. A suture hole 64 isformed behind the point 68 f. Current laparoscopic material removal offibroids requires the use of a corkscrew type instrument that is used tomanipulate exposed fibroids. After an incision on a uterine wall above afibroid is made, the fibroid is exposed and the corkscrew instrument isscrewed into the fibroid. Traction is then placed on the fibroid andwith counter traction the fibroid is pulled out of the uterine wall.Unfortunately, often a conventional 5 mm pitch corkscrew does notprovide enough embodiment or grip in the fibroid tissue, and tractionresults in the corkscrew instrument being pulled out of the fibroidtissue. Larger pitch corkscrews of say 10 mm diameter can be used butwould require a larger skin incision. Repeated expulsion and reinsertionof the corkscrew may result in fibroid fragmentation. This is manifestedby bleeding and the scattering of pieces of fibroid in the abdominal andpelvic cavities.

During laparoscopic hysterectomy, the uterus is pulled from one side tothe other to expose uterine vessels for ligation and division. Typicallya 5 mm grasping forceps is used to achieve this. Unfortunately, the sizeof the forceps jaw does not allow for strong traction to be applied tothe uterine muscle. This results in the forceps being pulled off theuterine muscle requiring reapplication. Again a larger 10 mm forceps canbe used but this requires a larger skin incision.

An insert 30 which comprises the myoretractor 38 f enables the shaft 62f to be angulated (i.e. pivoted with respect to the rod 32). Thus thelaparoscopic instrument 10 having an insert 30 provided with themyoretractor 38 f is placed into a trocar port and then the myoretractor38 f can be angulated by manipulation of the handle 12 across thefibroid or uterus to allow the point 68 f to be driven into the fibroidor uterus. This enables the insert 30 to hook in and onto the fibroid oruterus. Traction of variable degrees can be applied without thepossibility of the myoretractor 38 f being pulled off like the corkscrewinstrument. The shaft 62 f of the myoretractor 38 f is made with anouter diameter sufficient to provide adequate traction by virtue ofbeing driven a sufficient distance into the fibroid of a uterus.

FIGS. 13a and 13b depict a further form of myoretractor 38 f′. Themyoretractor 38 f′ has a tip 68 f′ in the configuration of a broad hook.The shaft 62 f′ of myoretractor 38 f′ is formed from cylindrical stockof constant diameter and machined to form an inboard elongated recessthat terminates in the hook tip 68 f′. The myoretractor 38 f′ is used inthe same way as the myoretractor 38 f but the hook tip 68 f′ provides analternate traction mode. The hook tip 38 f′ may take the form of a ricehook or sickle hook.

FIGS. 13c and 13d illustrate how the functionality of a convention corkscrew instrument is enhanced by utilization with or incorporation intoan insert 30 f′. The insert 30 f′ is provided with a detachablecorkscrew tool 38 f′. Due to the ability of the insert 30 f″ to provideangulation of the tool 38 f′ a double grip is now available. A firstgrip is achieved in a conventional manner by using the insert 30 f′ withthe tool 38 f′ in line with the shaft of the insert 30 f′, as shown inFIG. 13c . A second grip is achieved by subsequently manipulating aninstrument 10 to which the insert 30 f″ is attached to pivot the tool 38f′ relative to the shaft as shown in FIG. 13 d.

FIG. 14 depicts a tool 38 g in the form of a cutting edge needle. Thecutting edge needle 38 g comprises a coupling portion 58 b, a shaft 62 gextending from the coupling portion 58 b and terminating in a cuttingedge 68 g. The cutting edge 68 g comprises planar cutting surfaces 70that taper to a central tip or point 72 f. Optionally, a suture hole(not shown) can be formed through the shaft 62 g behind the cutting edge68 g. The cutting edge needle 58 g may be used in a similar manner asthe needles 38, 38 a and 38 b but in situations where the needle isrequired to cut through tissue.

FIG. 15 depicts a tool 38 h in the form of a gastro-intestinal (“GI”)retractor.

During laparoscopic GI surgery, the liver, stomach, small and largeintestines may require traction or reflection to expose the surgicalfield. Typically this is performed by the use of graspers or bluntprobes.

The tool 38 f consists of a blunt or rounded presenting end 68 hprovided at an end of a shaft 62 h. The shaft may be in the form of aplanar shaft or plate; or, a shaft of circular cross section. Also theshaft may be made to different lengths. One or more (and in thisparticular illustrated embodiment three) scallops 74 are formed on theinner surface of the shaft 62 h, allowing for the retracted tissue to beretracted without excessive pressure being applied to it. Behind thepresenting part, a 2 mm-8 mm or larger suture hole 64 is provided. Thishole allows for a suture material or tape to be passed as the GIretractor traverses the area or organ of dissection. Typically, a sutureor tape can be passed across the stomach, renal vessels or any otherorgan or tissue mass.

In a broad sense each of the tools 38-38 h when provided with a suturehole can be considered to be a suture tool or device.

As embodiments of the instrument 10 can provide angulation approaching180°, and easily up to at least 150°, a long retraction bar can beintroduced into the abdomen and then angulated to sweep up the bowel andhold it from falling into the line of operation. In the same way,material can be wrapped around a bar, similar to a rolled up flag, andthen unfolded to place over tissue. A large collection bag can likewisebe introduced and placed into the abdominal cavity. A large deflatedballoon can be introduced and angulated into position and then blown upto protect organs and tissue during operations. It is also possible toleave such inflated balloons in the pelvis or around organs for a fewdays to prevent adhesion forming.

FIGS. 16a-16c illustrate a ski needle 38 i and associated insert 30 i.The ski needle 38 i differs from that depicted in FIGS. 6a-6c byreplacement of the suture hole 64 with a slot 64 i. The slot 64 iextends longitudinally of the shaft 62 i and is closed at its oppositelongitudinal ends. Slot 64 i may be in the order of 4 mm in length andapproximately 0.6 mm in width. The slot has a transverse opening 81extending from a midpoint of the length of the slot 64 i. In oneembodiment the slot 81 has a width of approximately 1 mm.

The provision of the slot 64 i allows for suture material to beselectively engaged and disengaged from the needle 38 i during tissuesuturing. Further, the suture material is able to slide in the slot 64 iin either a forward or a backward direction. The slot 64 i allows forcontinuous suturing as the suture is introduced or extracted from theslot 64 i as the needle is introduced or withdrawn through tissue. Whensewing in a forward direction the suture is introduced into the slot 64i before the needle is passed through tissue. The suture would then beextracted from the slot 64 i via the opening 81 after passing throughthe tissue but before the needle is withdrawn. In a reverse procedurewhere a needle 38 i is introduced first and the suture engaged into theslot, the suture would be pulled through the tissue and then disengagedfrom the slot 64 i before the next pass. This now enables a surgeon toperform a mattress stitch in a manner substantially easier and quickerthan using a conventional needle and needle holder.

In all of the embodiments of tools described hereinbefore which have ormay have a suture hole 64, the hole may be replaced with a slot 64 i asdescribed hereinabove to enable continuous suturing. The term “sutureapertures” is used as a general term to cover and refer to both a suturehole 64 and a suture slot 64 i.

Tools provided with a suture slot 64 i can be used with all suturematerials. Moreover, such tools may be used with a modified barbedsuture in which the suture is formed with one or more loops at a freeend that can selectively engage the suture slot 64 i through the opening81. The provision of two or more adjoined loops at one end of the sutureprovides a degree of redundancy in the event that one of the loopsengaged with the suture slot 64 i breaks.

Insulation can be applied to any of the tools 38 to allow cautery to beperformed (specifically a needle tool such as needles 38 a or 38 b toperform ovarian drilling) or electrical cautery dissection to beperformed on the tool 38, thereby protecting the tissue behind the tool38, for example the ureteric tunneller, where peritoneum is incised overit.

FIG. 17 depicts an insert 30 j provided with a detachable tool 38 j inthe form of a scalpel. The tool comprises a scalpel holder 90 having acoupling 58 b at one end and shaft 62 j that extends from the coupling58 b and is configured to releasable hold a scalpel blade 92. Theability to pivot the scalpel blade 92 in vivo by manipulating theinstrument 10 (i.e. opening and closing the handle 12) to which theinsert 30 j is attached assists in morcellation of large uterus andfibroids.

FIG. 18 depicts an insert 30 k provided with a detachable tool 38 k inthe form of a peeling blade 94. The peeling blade 94 has a configurationsimilar to a potato peeler. The blade 94 has two mutually facinglongitudinal cutting edges 96 a and 96 b on opposite sides of alongitudinal slot 98. The thickness of tissue that can be cut/sliced byuse of the peeler blade 94 is dependent on the configuration of theblade 94 including the width of a slot 98. The insert 30 k is used in asimilar manner and for the same purpose as the insert 30 j.

FIG. 19 depicts a tool 38 l in the form of a mesh tunneller that may beincorporated or otherwise attached to an associated insert 30 forincorporation with a laparoscopic instrument. The tool 38 l is providedat a distal end with spherical tip 68 l that is attached to a telescopicshaft 80. The shaft 80 is telescoped in and out by an internal steelcable or wire 82 that can be wound in or out from a modified handle ofthe laparoscopic instrument 10. Winding the cable 82 out causes relativeextension of tubes 84 a, 84 b and 84 c which together form thetelescopic shaft 80. Winding the cable 82 in results in the tubes 84 a,84 b and 84 c retracting successively into each other. The spherical tip68 l can be provided with a suture opening 64 l. The opening 64 l may bein the form of a slot that opens onto an external surface of thespherical tip 64 l; or a through hole.

The tool 38 l is incorporated as a part of a ureteric tunneller similarto those depicted in FIGS. 8a-8c and is used as follows. The ureterictunneller can be used to tunnel a channel beside the rectum for thesacrum promontory to the vagina or cervix for treatment of genitalprolapsed involving the uterus and vagina. Mesh is attached to thevaginal vault or cervix and placed in a channel created beside therectum in the retroperitoneal space and then attached by sutures orstaples to the anterior spinal ligament over the sacral promontory. Thisprocedure can be achieved by open surgery or by laparoscopic surgery.

Typically in the prior art the channel is created by dissecting open atract beside the rectum and closed by suturing after a mesh is securedto the vagina and sacrum. This is time consuming and requires advancedlaparoscopic suturing skills if performed by the laparoscopic route.

The tool 38 l enables creation of a channel to place mesh without opendissection and closure by suturing of the channel created. This can beused to tunnel under the peritoneum from the sacral promontory to thevagina or cervix. The spherical tip 68 l forms an advancing dissectorhead and can be attached to either a fixed length shaft or a telescopicshaft 80 as shown in FIG. 19. The shaft can be made from metal orplastic and is capable of being bent but is able to straighten to passthrough a 10 mm trocar during laparoscopy. This may be formed as eitherreusable or single use. After the mesh tunneller has traversed thechannel, an incision is made over the tip 68 l to allow it to beexposed. A suture loop tied to a mesh is looped about the slot 64 l andsecured to the narrower shaft 80. The suture is pulled through thechannel together with the mesh and then the mesh is stitched to thesacral.

FIG. 20 depicts a form of coupling piece 58 b′ that may be used tosupport scalpel blades at different angles. The coupling 58 b′ is amodified form of the coupling 58 b shown in FIGS. 17 which supports thescalpel blade 92. With the coupling 58 b′, a shaft 62 j′ is formed witha substantially rectangular cross sectional shape with blade holders 100a and 100 b on two mutually perpendicular sides of the shaft 62 j′. Theblade holders 100 a and 100 b are each able to support a scalpel blade(not shown). Of course however only one scalpel blade will be coupled tothe coupling 58 b′ at any one time.

FIGS. 21a-21c depicts an insert 30 m with a detachable tool 38 m in theform of a myoma drill. The tool 38 m is provided with a coupling 58 b atits proximal end arranged to engage the coupling 58 a. The coupling 58 ais pivotally attached to the rod 32 via a linkage mechanism 44 m.

The coupling between the coupling parts 58 a and 58 b may be in the formof a screw thread, lure lock, or other type of coupling. The linkagemechanism 44 m comprises a cam plate 104 (see in particular FIG. 21c )having a large circular portion 106 and an integral small circularportion 108. The two portions 106 and 108 have centres that are axiallyaligned but are formed with holes 110 and 112 respectively which areaxially offset from each other. The large circular portion 106 is alsoformed with an inboard arcuate slot 114. A pivot pin 54 m passes throughthe hole 110 and into attachment head 42 m of the insert 30 m. Rod 32 isattached to the small diameter portion 108 of the cam plate 104 by afurther pivot pin 116 that extends through the hole 112. A cam guide 118extends transversely from the coupling part 58 a and through the slot114. Insert 30 m is received inside a sheath 14 with the ball 40 arrangeto engage the handle 12 and the head 42 m arranged to abut the distalend 24 of the sheath 14. On actuation of the handle 12, the rod 32slides relative to the sheath 14 and due to the offset nature of theholes 110 and 112 and the engagement of the guide 118 in the slot 114the tool 38 m will pivot about the pivot pin 54 m.

With the advent of single port laparoscopic surgery various combinationsof the tools 38 and associated inserts 30 can be used.

Currently, single ports laparoscopy consists of a 25 to 35 mm port withthree instrument channels. A larger central port is for a camera and twolateral ports for instruments. Laparoscopic instruments are inserted andremoved as the operation demands. This can be time consuming and requirecrossing over of instruments rather than withdrawing and insertion ofinstruments to save time.

Current single use ports do not rotate and instruments have to be pulledin and out and exchange. In embodiments of the present inventionrotating ports can be used enabling the desired instrument 10 andcorresponding insert 30 to be brought into the desired position for use.

Also embodiments of the various described suture needles would eliminateneedle introduction and needle handling during single port suturing.

Modifications and variations to the tools, systems and instrumentsdisclosed herein that would be apparent to those of ordinary skill inthe art are deemed to be within the scope of the present invention thenature of which is to be determined by the above description and theappended claims.

1. An insert for a laparoscopic instrument having a handle and an outersheath coupled to the handle, the insert comprising: a rod configured tofit within the outer sheath and engage at its proximal end the handle,and a tool demountably coupled to a distal end of the rod.
 2. The insertaccording to claim 1 comprising a linkage mechanism which convertslinear motion of the rod relative to the outer sheath to a pivotalmotion of, or a component of, the tool of up to at least 150°.
 3. Theinsert according to claim 2 wherein the tool is provided with a sutureaperture opening for receiving a suture.
 4. The inert according to claim3 wherein the suture opening is either a suture hole or a suture slotwherein the suture slot extends along a length of the tool and isprovided with an opening enabling a suture material to enter the sutureslot.
 5. The insert according to claim 4 wherein the tool comprises asuture needle.
 6. The insert according to claim 5 wherein the needlecomprises a straight shaft.
 7. The insert according to claim 5 whereinthe needle comprises a curved shaft.
 8. The insert according to claim 5wherein a distal end of the needle: (a) tapers conically to a point; (b)tapers linearly to a point to produce a cutting edge; or (c) is providedwith a rounded end.
 9. The insert according to claim 4 wherein the toolcomprises (a) a ureteric tunneller having either a straight shaftprovided with one of a spherical tip or an ellipsoid tip, (b) adissector, or (c) a myoretractor having either a straight shaft or acorkscrew shaped shaft.
 10. (canceled)
 11. The insert according to claim9 wherein the dissector comprises a shaft, a reduced thickness tip at adistal end of the shaft and a straight edge at a distal end of the tiplying perpendicular to a length of the shaft.
 12. The insert accordingto claim 11 wherein the reduced thickness tip has at least one planarsurface and/or wherein the reduced thickness tip is curved inconfiguration.
 13. (canceled)
 14. The insert according to claim 12comprising a longitudinal slot formed in the reduced thickness tip andopening onto the straight edge.
 15. The insert according to claim 11wherein the shaft is provided with a dovetail slot extending along alongitudinal axis of the shaft and inboard of the tip.
 16. (canceled)17. The insert according to claim 4 wherein the tool comprises amyoretractor having a straight shaft and a hook at a distal end of theshaft.
 18. The insert according to claim 2 wherein the tool comprises ascalpel.
 19. The insert according to claim 2 wherein the tool comprisesa peeling blade provided with a longitudinal slot the slot havingmutually facing longitudinal cutting ends.
 20. An insert system for alaparoscopic instrument having a handle and an outer sheath coupled tothe handle, the insert system comprising; a rod configured to fit withinthe outer sheath and engage at its proximal end the handle; and aplurality of tools each being demountably attachable to a distal end ofthe rod.
 21. The insert system according to claim 20 wherein theplurality of tools comprises of at least two tools of differentconfiguration.
 22. The insert system according to claim 20 wherein theplurality of tools comprise two or more of the tools selected from thegroup consisting of: a suture needle; a ureteric tunneller having astraight shaft provided with a spherical tip; a ureteric tunnellerhaving a straight shaft provided with an ellipsoid tip; a ureterictunneller having a curved shaft provided with a spherical tip; aureteric tunneller having a curved shaft provided with an ellipsoid tip;a dissector; dissector having a shaft, a reduced thickness tip at adistal end of the shaft and a straight edge at a distal end of the tiplying perpendicular to a length of the shaft; a myoretractor havingeither a straight shaft or a corkscrew shaped shaft; a myoretractorhaving a straight shaft and a hook at a distal end of the shaft; ascalpel; and a peeling blade provided with a longitudinal slot the slothaving mutually facing longitudinal cutting edges; any of the abovetools having a suture slot wherein the suture slot extends along alength of the tool and is provided with an opening enabling a suturematerial to enter the suture slot.
 23. A method of using a laparoscopicinstrument to perform a laparoscopic surgery, the method comprising:inserting a linkage portion of a laparoscopic insert through a trocarinto a body cavity; manipulating a handle of the laparoscopic instrumentto: pivot the linkage portion within the body cavity from an insertionstate to a pivoted state; drive a tool coupled to the linkage portioninto a body tissue; and pivot the linkage portion within the body cavityback to the insertion state; and removing the linkage portion of thelaparoscopic insert from the body cavity through the trocar.